A CASE REPORT J BEN HAFDHALLAH S BOURKHIS F SNENE MAGHODHBANI H RAJHI N MNIF CHARLE NICOLLES HOSPITAL TUNIS TUNISIA MK6 OBJECTIVES Evaluate the role of imaging modalities in the diagnosis and management of the posterior ID: 577840
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POSTERIOR IMPINGEMENT SYNDROME : A CASE REPORT
J. BEN HAFDHALLAH, S. BOURKHIS, F. SNENE, M.A.GHODHBANI, H. RAJHI, N. MNIF. CHARLE NICOLLE’S HOSPITAL, TUNIS, TUNISIA.
MK6Slide2
OBJECTIVES Evaluate the role of imaging modalities in the diagnosis and management of the posterior
tibio talian syndrome. It includes clinical situations secondary to entrapment of bony elements or soft tissue between the posterior edge of the tibia and calcaneus during plantar flexion of the ankle.Slide3
A CASE REPORT This is a 27-year-old male who usually complains of posterior ankle pain exacerbated by plantar flexion or
dorsiflexion . An Achille tendinopathy was firstly suspected.Slide4
RESULTS
AN ULTRASOUND EXAM OF ACHILLE TENDON
Tibio
talian
intra
articular
liquid
Right
anlke
/ axial planeSlide5
Lateral ankle radiographs
RESULTS
Lateral ankle radiograph shows a prominent posterior process of the tibia and a long posterior
talian
process .Slide6
MR imaging
RESULTS
Sagittal
(T2 / T1-
weighted
) and axial (T1-
weighted
)
MR image shows focal thickening of
posterior
pericapsular
tissue ( )
but normal bone marrow signal intensity in the
postérior
process
. Note the
tibio
talian
intra
articular
liquid ( ).Slide7
TREATMENTRESULTS
A posterior
tibio
talian
syndrome
was
diagnosed
. The patient
had
an
arthroscopic
treatement
with
supression
of
prominent posterior process.
Clinical evolution marked by an improvement.
Lateral ankle radiograph before and after surgery shows a disappearance of prominent posterior process ( ).Slide8
DISCUSSION
Posterior impingement has been described under a variety of different names, including os trigonum syndrome and posterior tibiotalar compression syndrome.
The condition arises from compression of the soft tissues between the posterior process of the talus and the posterior tibia on plantar flexion of the ankle.Slide9
CAUSESThe syndrome can develop after
a significant acute injury: avulsion of the posterior talo-fibular ligament.
talar
fracture.
disruption of an
os
trigonum
.
A chronic injury:
a repetitive
forced plantar flexion of the foot
(ballet
dancers
).
DISCUSSIONSlide10
CLINICAL FEATURESThe syndrome usually
manifests clinically when a significant soft-tissue component forms.
Clinical
symptoms
usually consist of posterior ankle pain exacerbated by plantar flexion or
dorsiflexion
.
Clinical
examination shows:
Posterior tenderness anterior to and not involving the Achilles tendon.
Occasionally
, palpable soft-tissue
thickening
DISCUSSIONSlide11
CONVENTIONAL RADIOGRAPHS
Conventional radiographs may show a prominent lateral talar process or os trigonum.
IMAGING FEATURES
DISCUSSIONSlide12
US exam Ultrasound is a useful technique for accurate real-time guidance of therapeutic injection.
IMAGING FEATURES
DISCUSSIONSlide13
MR imaging
MR imaging shows:
Bone
marrow edema.
A fracture line.
fluid in
the
synchondrosis
.
Posterior
capsular
or ligament
thickening with intermediate to low signal intensity
on T2-
weighted
images.
IMAGING FEATURES
DISCUSSIONSlide14
The integrity of the ligaments.
Possible associated flexor hallucis
longus
abnormality or other internal derangement, which can alter any planned
surgical
approach
.
Enhancement
after
intravenous
administration of gadolinium contrast material can highlight small focal areas of
synovitis
.
MR
imaging
IMAGING FEATURES
DISCUSSIONSlide15
ManagementImaging-guided injection (a steroid or local
anesthetic): Most cases of posterior impingement of the ankle respond to conservative treatment (physiotherapy).
Surgery: in resistant cases.
IMAGING FEATURES
DISCUSSIONSlide16
CONCLUSIONImpingement syndromes of the ankle are usually
a clinical diagnosis.
Conventional
radiograph
plays an important role in the initial assessment
of
these
conditions.
MR imaging is most useful in posterior impingement, where it can identify the relative contributions of the osseous and soft-
tissu
components.